Here’s the report, press release below. It looks like pretty sensible stuff to me, homeopaths can’t expect special treatment among all forms of medicine, if the evidence actively shows it doesn’t work, then that’s that. I have to say what really frightens me about all this is the MHRA: if regulation is so political that they can fall into holes over sugar pills, it tells a frightening story about their wider activities.

EDIT: Just whizzed through the report, like their one on abortion, it’s a really fantastic bit of pop science writing on evidence based medicine.

While you’re here, can I ask a favour? A lot of homeopaths and GPs who like to give out sugar pills are appearing on the news, claiming that RCTs are no way to test if a pill works, cherrypicking, etc. It would be great if people could note the name and the claim here or in an email (ben@badscience.net as ever) so we can track how much harm these people are doing to the publics’ understanding of evidence, in the course of this “special case” pleading for their own pills.

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If you like what I do, and you want me to do more, you can: buy my books Bad Science and Bad Pharma, give them to your friends, put them on your reading list, employ me to do a talk, or tweet this article to your friends. Thanks!
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Groinhammer said,

fgrunta said,

I just saw this story break on BBC News. They brought on a Homeopath GP who just went and told I don’t know how many millions of viewers that the “evidence is clear” that homeopathy works and she then proceeded to start quote papers.

Grrr….

progjohn said,

Excellent outcome, a clear and unambigous finding that homeopathic rememdies are completely useless and should neither be paid of nor certified by any government department. Now settle back to await the frantic quacking of the homeopathy industry. Conspiracy theory anyone?

ALondoner said,

An excellent report, nice to see that MPs can sit down, review the evidence and then say something intelligent.

On the other hand, The BBC (and some other news outlets) seem to be so obsessed with giving each side of the story, they make it sound like there is reasonable evidence for both points of view.

When someone is found guilty of a crime, journalists doesn’t put guilty in quotation marks. Nor do they pick a self appointed expert to rant about why that person was actually not guilty. So why doesn’t the BBC simply report that supporters of homoeopathy say it works, but all independent reviews shows that it does not.

Instead, we get “many people – both patients and experts – say it is a valid treatment and does work”, without at least caveating that with “but all systematic reviews show it is no better than placebo” and explaining who these “experts” are. Experts in giving homeopathy perhaps, but are they experts in telling whether it works better than placebo?

Just sent a few comments to the BBC via their well hidden complaints website:

Groinhammer said,

..and the BBC have edited the original report already, replacing the experts line with the well worn and contemptable: “There is good evidence that homeopathy works, for example in animals and babies, neither of which experience placebo effects.”

TomP said,

It strikes me that, in the normal run of polite parliamentary language, their comments about Professor David Harper rank as a fairly hefty smackdown:

“We were troubled that the Chief Scientist at the DH seemed to be out of step with the accepted scientific consensus on the question of efficacy… We recommend that the Government Chief Scientific Adviser and Professor Harper get together to see if they can reach an agreed position on the question of whether there is any good evidence for the efficacy of homeopathy and whether there is a genuine scientific controversy over the efficacy of homeopathy and publish this.” (p.19-20)

I think that, in short form, essentially means “stop being weird”.

Bhoddhisatva said,

Listened to Radio 4 news at lunchtime (1-1.30) – two ” professors” – one saying bunkum was right, nothing in the “water”, placebo effect.

Other kept saying that “70% of patients benefit from homeopathy” and “homeopathy doesn’t fit into the controlled studies” … I’d have hit him in frustration at his self-serving, blind ignorance and smug superiority but I was dealing with snow on the M40 …
Fortunately other prof came back and said “yes but they would get better anyway most of the time without taking a sugar pill … as you know …”.
It’s only a few million but as he said, it’s the principle and that few million might be what they’re lacking when YOU need some potent real medicines but the NHS can’t afford them.

phayes said,

“I just saw this story break on BBC News. They brought on a Homeopath GP”

The report says:

“NHS doctors should not refer patients to homeopaths.”

“When you have enough gold-standard evidence, stop researching”

And there was never really any justification for homeopathy research, not even in the laboratory, but homeopathy RCTs in particular have been pointless and unethical “pathological science” since more than a century ago.

Crabbadon said,

Vetstudent1 said,

ITV News lunchtime news today (www.itv.com/news/fullprogramme/ not entirely sure how long that link will contain the lunchtime news, probably until 6pm this evening.)

Dr Sara Eames of the Royal Homeopathic hospital stated “there is quite a lot of evidence for homeopathy, and there are even quite a lot of controlled trials in homeopathy, we’ve done far more than 100 and there are many more that are positive than are negative an so it’s rather dissapointing that the committee hasn’t taken that into consideration.”
Another example of the media trying to give what they see as a balanced view and making both sides seem equally plausible.

Vetstudent1 said,

I actually laughed out loud when I saw that today.
It was also fairly interesting how they represented both sides. The ‘expert’ for the homeopathic side was Dr Eames, and then in contrast the expert against homeopathy was a non-scientifically qualified MP (or at least if he was is wasn’t shown.) So I imagine that could create an impression that the homeopath was the more knowledgeable ‘expert’.

GawainTowler said,

Hard on the heels of the evidence for the effects of high dilutions published in the current volume of ‘Homeopathy (see 25 January news item) comes yet more evidence for the effect of high dilution homeopathic medicines in a study published in the high impact, highly respected ‘International Journal of Oncology’.

I have read the abstract, but as a layman it is impeneterable stuff. I write as I discover from the website that the EU is funding this sort of stuff to the tune of 1.5 million euros

Surely ever point there in re magnesium chloride, fibromyalgia, botox, etc. could equally be applied to homoeopathy?
Why has no-one referred a homoeopathic doctor to the GMC for advocating and prescribing homoeopathic treatment and claiming it has real, “more than placebo” benefits when all the evidence suggests it doesn’t?

muscleman said,

And you can bet that this was handled not by the Beeb’s and press’s science or health teams but by their politics units since it was a select committee report. That sound you hear is the first mentioned journalist’s teeth grinding.

I am reminded of when the Guardian spoiled its developing Brownie Points in Science reporting by allowing a Sports reporter to write an article on Autism while pretending they were a ‘health’ reporter. You could hear Alok Jha quivering all they way up here in Scotland.

Dr Charlotte MENDES DA COSTA GP 11.45ish, “There is good evidence it works over 100 randomised control trials, over half show positive responses. Outcome trials & studies, eg Bristol homeopathy hospital, 6500 patients over 50% significant improvement in 2005.”
Dr Sarah EAMES President of the Faculty of Homeopathy 15.15ish, “Over 100 controlled trials most show benefits, also v large patient outcome studies from homeopathy hospitals.”
And responding to pharmaceutical reps point that 200 randomised trials & meta analysis / systematic reviews show nothing – “Interepretation of evidence by other people is completely different. Far more positive outcomes than negative in trials. Statistics don’t have the answer for everything, here we have prime example one person thinks one thing one person thinks another thing.” (which makes me slightly concerned at how she judges latest medical best practice / which drugs to prescribe – glad she’s not my doctor)

I noticed a report on the decision on homeopathy on BBC Radio 4’s “The World at One” today (22nd Feb). This has been mentioned on your blog by Bhoddhisatva, I’ll try to fill you in a bit more.

You can find the program here: www.bbc.co.uk/programmes/b006qptc The headline report starts at ~3mins 40 => ~4mins 40 with a full report at ~25:30 => End. The speakers where Dr. Micheal Dixon and Phil Willis.

Dr. Dixon stated (mostly paraphrased):

“many patients … are helped by homeopaths”
“70% helped in 2 large trials”
“only looking at randomised controlled trials is old fashioned”
“it is a fundamentalist view of science”
“I see patients getting better day by day”

FelixO said,

DrJG said,

“..and the BBC have edited the original report already, replacing the experts line with the well worn and contemptable: “There is good evidence that homeopathy works, for example in animals and babies, neither of which experience placebo effects.”

I think you are being somewhat unfair on Auntie there, as it is clear in the article itself that they are quoting Robert Wilson, of the British Association of Homeopathic Manufacturers. OK, criticise the BBC for heavily overdoing the “balance” bit, but don’t put words into their own mouth.

skyesteve said,

As Ben said, Dr Mike Dixon on Radio 4 today said “the science comittee’s views on homoeopathy are fatally flawed because they were old fashioned and only looked at randomised controlled trials”. So now evidence-based medicine is “old fashioned”. And if you want to know more about him see below…

Then we have Dr David Reilly, the charismatic consultant at the Glasgow Homoeopathic hospital who said on Radio Scotland this evening (again a paraphrase) “this is a belief report – because they couldn’t find evidence for how it worked they believe that it doesn’t work. There’s a scientific controversy” (when, of course, according to Nature, The Lancet, etc. there is NO controversy – it doesn’t work beyond placebo). “70% followed up after a year felt better” (therefore, despite no control group, this means it works). “This report is driven by fundamentalists” (that’ll be me then) “who are misusing science and undue media influence to get their point across (paraphrase)” (so now demanding that the multimillion pound homoeopathic industry carries out high quality, randomised, double-blind control trials to prove that homoeopathy does something more than placebo is misusing science…). He also said that the report ignored four metanalysis that favoured homoeopathy and only referred to a fifth which did not. Oh, and apparantly allergy desensitisation was invented by homoeopaths. so now you know.

FelixO said,

Michael Gray said,

To those who bitch about the cessation of NHS funded trials of magic water:
Homeopaths milk more than enough excess cash to fund their *own* high-quality trials. (Of course they never will, as they know what the outcome will be.)
Stop stealing taxpayers’ money to prolong your dangerous delusions.

DrJG said,

Much of me welcomes this report and its support of good scientific evidence over woo.

But I am also a doctor with patients to treat. Evidence-based medicine is all very well, but for a lot of the patients I see, there is little reliable evidence on which to base treatments. Even where it does exist, the patient sat in front of me may well be from a very different demographic from those from whom the best available evidence was gathered. But that does not absolve me of my duty of care – and as a GP I do not even have the option of discharging those patients where careful investigation has failed to suggest a nice neat well-proven therapeutic approach.

Of course, the right approach is to fully educate these patients fully in the connections, or otherwise, between symptoms and disease processes, taking in the role of psychosomatism amd socio-economic factors along the way. And in the rest of the ten-minute consultations we will chat about the weather and watch the squadron of pigs flying past the consulting-room window, and for an encore I will sort out all of those trivial little socio-economic trifles.

What I am getting at is that the pragmatic side of me, the side that sees the practice of medicine as as much an art as a science, reckons that there is probably a need for placebos, and even that honesty from a doctor is not necessarily in a patient’s best therapeutic interests. Take analgesia – if I prescribe a perfectly reasonable analgesic and enthusiastically promote it as the greatest thing since sliced bread, my patient is likely to get a better symptomatic response than if I prescribe the same drug but give a more honest appraisal of its chances – the same is likely true of warnings of potential side effects.

What, ultimately, are we trying to achieve with the practice of medicine? If we are to limit it to what we can currently prove, and tell the rest of our patients to go away and stop bugging us, then it is probably time for me to quit. If we set our aims wider, and include helping our patients to feel better, we probably need those placebos.

I am not even convinced by the financial arguments against the homeopathic hospitals. I strongly suspect that the patients treated there will tend to be those who have already been extensively investigated conventially. If the homeopathic option was suddenly removed, these patients would not disappear from the NHS workload.

And no, none of this makes me want to defend the provision of homeopathy, or claim it is anything more than a placebo, but I do know we need to think hard about why it does get relatively high patient satisfaction scores.

kkbundy said,

Ah, the light of reason finally overcomes the black of superstition and illogical thinking. Ha!! You have to wonder what will be next. State funded alchemy? Parliamentary Phrenology? That holy grail of all benefits to mankind, Federal Astrology?

It’s sad it went on as long as it did. Between this and fundamentalist religion, our future really scares me.

skyesteve said,

@DrJG – as a fellow doc I understand fully what you say. Of course, a lot of the benefits of any drug or treatment includes the way in which we as docs “promote” it to our patient.
You use the example of simple analgesia – I don’t doubt there’s an element of placebo involved but that’s not the main way it work (there’s a genuine pharmacological response to paracetamol or opiates or anti-inflammatories) and that’s not why we prescribe it.
But if we prescribe homoeopathy and we know that the evidence shows that it’s no better than placebo (i.e. there is no genuine pharmacological response) then we are knowingly prescribing a placebo for it’s placebo benefit.
If we do that without informing the patient that’s what we are doing then to me that is paternalism. But regardless of what I think both the GMC and BMA regard it as unethical from what I can gather.
I don’t deny that on an individual level people feel better and are helped by homoeopathy but why should the NHS fund it? It won’t fund herbalism (for which there is some evidence), it won’t adequately fund CBT in my area (for which there is some evidence), etc.
If people want to pay for homoeopathy out of their own pockets that’s fine by me. But if the NHS is to fund it then it should equally fund reflexology, hot stones massage or Shamanism.

owl said,

Plenty of “clever” posters here. Comments about fairness exactly matched by the dismissive nature of the commentary, although to be fair myself. You aren’t exactly the Beeb and required to be even-handed.

Much is made by you and others about the £4 million which the NHS currently invests in homoeopathy. If the people treated as a consequence of this investment don’t have homoeopathy available to them, there will be significant additional cost to the NHS, as they will be requiring treatment by some other means, but still within the NHS? Whether or not you think that homoeopathy is all about placebo, these are people who need treatment, these are people who have often been failed by conventional treatment (dustbin cases), and they are going to continue to require treatment, and therefore continue to be a cost to the NHS. Unless, that is, you suggest, they quietly go away and continue to suffer and/or die.

I suppose they could be given medication, often many different medicines at once, which have rarely been tested for their combination impact, and often medication being given for something for which it was never tested in the first place.

On a separate note, I think Dr JG is more credible than anyone else who’s posted on here. At least he appears to have given rational consideration to the situation.

skyesteve said,

@owl – I think you miss the point. These people can be helped by things currently under-funded or not funded by the NHS such as CBT and other forms of psychological therapy.
Just giving them a sugar pill and pretending it’s something more than that is, in my humble opinion, crap medicine.
Far better in my view to be honest and say “we may not be able to solve this problem but hopefully we can help you live and deal with it more effectively”.
Of course, patients have a choice and will chose doctors that suit their own “illness model” so I can only speak for myself but given the choice between hoodwinking and openess I know which I would prefer.
You haven’t addressed the ultimate point – if the NHS is to fund homoeopathy because it helps make people feel better then why not aromatherapy, massage therapy, yoga classes, reflexology, crystal therapy, Shamanism, meditation, etc., etc.
Of course, if you think the NHS should fund all these activities then that is a consistent view to take but who is going to fund it all and why should it be at the expense of beds and proven effective treatments?

skyesteve said,

P.S. the figure of £4 million has got to be a gross under-estimate. There are 4 NHS funded homoeopathic hospitals in the UK – surely they don’t survive on a budget of £1 million each.
I help to look after a rural community hospital with only 12 beds and that costs nearly £2 million a year to run.
Anyone like to find out the actual budgets for running the 4 homoeopathic hospitals?

pv said,

Dr JG, I would suggest that homeopathy gets “high satisfaction” rates because people are good at deluding themselves. That shouldn’t be an excuse to perpetuate people’s ignorance (as some medical practitioners might wish) or take advantage of it (as Boots and all homeopaths do). Homeopathy is medical fraud.

I would suggest also that withdrawal of homeopathy on the NHS, or even completely, won’t actually prevent people recovering from what ails them. Some of the patients might whinge a bit, which might be irritating for everyone else, but there is no human right or law that says one has to be granted every whim in life – and certainly not at the expense of someone else’s more pressing or more real medical need.

There are some things that could be done for sufferers of self-limiting ailments. A bit of honesty for a start. Doesn’t the placebo effect work with honesty if packaged and delivered in the appropriate way?

Then there are all those other things that some of us wish were dispensed through the NHS to make us feel better, like a large single malt whiskey every so often, a holiday in the Seychelles, maybe a small lottery win. Not everything has to cost money though… take the dog for a walk, do the gardening, or practically anything that’s physically or mentally stimulating.

pv said,

I should add that if homeopathy were absolutely free then no-one should have cause to complain. It’s the enrichment of the likes of Boots, Nelsons, Boiron and all homeopaths without exception that is completely objectionable, because they lie through their teeth whenever the physical impossibility of homeopathy is pointed out or even demonstrated. And they hide behind other people’s delusions, which they actively feed and encourage (look at the “sciencey” utter drivel spouted by Lionel Milgrom or example).

Rothermere said,

If some modern, high cost medicines with strong, evidence-based clinical benefit are considered too expensive to provide free on the NHS it might be useful to apply the same cost-effectiveness criteria to homeopathy.

pberry said,

You contend that by withdrawing homeopathy on the NHS such patients would now need to be treated conventionally so is there a cost saving? Yes, it would still be £4m saved because all that’s being done is removing a useless step in treatment. If a patient ultimately needs conventional treatment they’re going to cost the NHS at some point, whether fobbed off with magic pills for a few months or not. Or look at it this way, if they get better anyway with no intervention then they’d never affect the stats.

TotallyHeartsScience said,

I actually paid for a copy of this (£18!) just so I could satisfy myself that it was nonsense.

Firstly the journal is not of high impact factor as is suggested in the linked piece.

Hilariously they use *homeopathic* dilutions of their test remedies than add them to cells at 0, 1.25, 2.5, 5 and 10 μl/ml and claim to see a dose dependent effect. Nuts!!

The inhibitory effect on cancer cells is only marginally different from the sizable inhibitory effect of the solvent that they use to dilute the remedies (we can guess due to the fact that they have not showed any stats these small differences are not statistically significant). In most of the paper, they seem to have omitted the solvent control and are comparing against and unknown “control”.

You’ve got to question the peer review process here.

And on the main topic of this blog, excellent news indeed! Lets see if anything actually changes.

Dag-Erling said,

kim said,

I think JG raises some interesting points. I also think that s/he probably knows the answer to “why it does get relatively high patient satisfaction scores.” The answer is that homoeopathic practitioners listen attentively to what patients say and take them seriously. That makes a huge difference for people who have been ignored and patronised by medical practitioners.

skyesteve said,

@kim – “The answer is that homoeopathic practitioners listen attentively to what patients say and take them seriously” – yes – and so do I. Homoeopaths don’t have a monopoly on being kind and compassionate and caring and attentive (and many of my patients lives would be much improved if I had a hour to spend with them).
What I don’t do is fib to them by giving them something I know to be no more that a sugar pill and pretend that it’s something more than that because, frankly, that is deception which has no place in a good, high-trust, doctor-patient relationship. Now you may say that the homoeopaths are not pretending and that they genuinely believe that their pills are more than placebo. That’s fine if it’s a non-doctor and the patient is paying for it.
However, if things are funded by the NHS and practised by medical doctors those doctors have an obligation to look at the evidence and inform the patient that the evidence shows that homoeopathy is no better than a sugar pill – even if they don’t believe the evidence for whatever bizarre reason. But to ignore the evidence and keep you patient ignorant of it too is, in my view, unethical and poor medicine.
But perhaps there’s always room for doubt…

IainP said,

Decided to submit a complaint (thanks ALondoner!) and see what happens – never tried it before; hopefully I’ll get a response:

“This morning’s interview at around 8:10 with Chris French and Dr Sara Eames appeared to be an extremely misleading way to report the case for and against homeopathy. Reporting of a scientific issue using a debate between two experts is a poor way of articulating the science behind the case. These 5 and a half minutes of the programme would have been far better spent on an unbiased report explaining published evidence on whether homeopathy has been shown to work.

Furthermore, while one guest, Chris French, attempted to explain the concensus among almost all scientists working in evidence based medicine, he was interrupted by the interviewer (Bill Turnbull, I believe). The interviewer tells the guest (who appears far better informed on the science in question) that there is ‘debate’ over homeopathy. However, this ‘debate’ appears to be the perception of the interviewer and is not borne out by the scientific concensus based on the combined evidence from all scientific studies on the subject.

I would like to know if the BBC intends to continue reporting science in this uninformative ‘debate’ format. Additionally, I would like to know whether the programme’s editor believes that a 5 minute item reporting impartially on the scientific evidence of homeopathy would be less informative than the debate that was actually featured, and why.”

elvisionary said,

@owl, the question isn’t how much should be spent – it’s what public money should be spent on. You’re clearly right that any treatment costs money, whether it is effective or not. And DrJG is clearly right that there are elements of medicine that are more art than science. But does that make it right to spend public money on placebos and then pretend to the recipients of this public service that they are getting something different? To me, that’s simply inappropriate.

Let people spend their own money in whatever stupid way they see fit. But when it’s your money and mine, certain standards apply, and to my mind homeopathy falls well below those standards. (I feel the same way about faith schools – but that’s a whole other question!)

pv said,

@kim said,
February 23, 2010 at 1:28 pmI think JG raises some interesting points. I also think that s/he probably knows the answer to “why it does get relatively high patient satisfaction scores.” The answer is that homoeopathic practitioners listen attentively to what patients say and take them seriously. That makes a huge difference for people who have been ignored and patronised by medical practitioners.

This is in fact a commonly repeated slander against proper GPs.

There certainly are differences between most homeopaths and most GPs. For a start GPs carry a great deal of responsibility whereas homeopaths are simply play acting, with no responsibility to anything except their own delusions. GPs patient lists are usually several magnitudes larger the homeopath lists. GPs occasionally get to deal with real, serious illnesses whereas homeopaths get to pander to their clients’ delusions while their clients’ illnesses resolve themselves.

And once more I think it’s worth pointing out that homeopathy’s record of curing non-self-limiting conditions is, after 200 years, precisely zero. It follows that not one single homeopath has ever prescribed/issued/recommended a homeopathic “remedy” that has cured a non-self-limiting condition.
It’s probably also fair to say that no homeopathic remedy has directly led to the resolution of a self-limiting condition (by definition they resolve themselves).

thenighttripper said,

A bit of information about the Royal London Homeopathic Hospital, from their own lips.
“The historic site of the RLHH on the corner of Queen Square and Great Ormond Street has undergone a comprehensive £20m makeover to transform it into a leading centre for integrated medicine.” (This was finished in 2005)
Their facilities include;

The Marigold Clinic was fascinating; “Quick acting and without adverse reactions, Marigold Therapy is suitable for people of all ages. Its gentle, noninvasive nature makes it attractive to patients. The non-painful procedure helps to remove even the youngest patient’s fear of treatment. It is also helpful for people for whom surgery is contra-indicated.”
And how helpful to know that, “No animals are used in the manufacture of Marigold Therapy preparations, making this therapy a natural choice.”
But all in all the level of services they provide suggests that the quoted figure of £4 million a year on homeopathic treatment is a complete fabrication. The problem is that the Homeopathic Hospitals tend to be within a group of hospitals, making it difficult to disaggregate the spend on each section. But they all have a 70% satisfaction figure.
And ginger yellow is correct, they don’t need beds, as, “Most inpatients (are)accommodated in local hotels while those requiring hospital admission are admitted to other Trust hospitals.”

Guy said,

Skysteve,
I don’t wish to get into defending homeopathy which is at best total placebo and more generally delusional fraud. However as a doctor I suspect you prescribe SSRI anti-depressants. Several hundred million are spent on these each year by the NHS. They are pretty effective, but sadly no more effective than placebo pills. Hopefully however you know this so are not deluding yourself. This isn’t a criticism of you but there are some inconsistencies within medicine.

penglish said,

There are lots of comments about the quality of the placebo effect above… As the son of a medical homeopath, and a former GP myself, I can comment on this.

As a GP, patients want to tell you about certain things – the colour of their snot, the effect of temperature, which side of their body the symptoms affect most… Many of the things they want to tell you about are of very little value in getting to a diagnosis and providing the right treatment.

If you are a homeopath, however, the things you want to know about, in order to choose the right “remedy”, are exactly the things patients are so keen to tell you about. I’m sure this is no coincidence.

The fact that a homeopath is extremely interested in the things the patient wants to tell him or her, must surely mean that the “doctor-as-drug” placebo effect will be much stronger than when the patient sees a doctor who tries to hurry them through these symptoms, and focus only on those that will lead to a diagnosis.

skyesteve said,

@Guy – always happy to discuss/debate and be pragmatic/willing to change but can I refer you to my post from the How To Defeat Wu thread (number 39) when I said:-

“In fairness, in contrast to other complimentary therapies, I actually have some time for herbalism because it can at least demonstrate a logical physiological basis and may, in the right hands, be as effective as “modern” therapy for some conditions – for example, the use of St John’s wort as compared to SSRIs in mild to moderate depression (although perhaps that’s a poor example given that both may not be much better than placebo…)”

Your statement re SSRIs is true for mild depression but less so for moderate depression but nonetheless you can see from the above post I am sceptical about their value even in those circumstances and that’s exactly what I tell my patients.

Guy said,

Steve, thanks for reply. The use of SSRI’s in primary care is placebo. I find this very uncomfortable, but it is true. Hospital studies in severe depression (very rarely seen in primary care) and publication bias have given the myth that they are highly effective drugs. Not sure where this argument takes me as I’d happily ban NHS homeopathy. Lots of interesting comments about use of placebos in this argument and others. The old days when prescriptions could be unlabelled, so placebos could be used, has gone. Not sure what the place of the placebo is in modern medicine. Wrapping it up as homeopathy however is definitely not the answer.

skyesteve said,

Hi Guy – thanks in return. Please believe me when I say I share your doubts about the value of SSRIs but a quick search of the Cochrane reviews would suggest that even in moderate depression they may be marginally better than placebo – there are a number of reviews which suggest that MAY be the case. For example:-

But you’re right – almost certainly they are of no value in mild depression and they are of limited (or perhaps even very limited) value in moderate depression.
The caveat to that is that depression as you know is not a homogenous disorder and the response is therefore not always predictable. In addition, there are clearly patients who become “dependent” on them.
So, yes, I do think long and hard before recommending someone with moderate depression to try an SSRI and I almost never even raise the subject until I have seen and assessed them once or twice.
What I never do is offer them an SSRI, tell them it is the thing that will help when all else has failed or talk it up way beyond what the evidence would suggest.
Anyway, we could ping pong this back and forth for a few more posts but let’s not (though feel free to respond to this post and I promise not to counter-post unless you say something too outrageous!).
Homoeopathy on the NHS just cannot be justified and that’s what we should be saying here loud and clear.

DrJG said,

@owl – thanks for the compliment, but if you can actually read any practical approaches from my rational considerations, I’d be very grateful if you could let me know, because I certainly can’t!

@pv – I largely agree with your comment on self-delusion, though wonder if you are slightly oversimplifying the placebo effect (insert emoticon of choice here). But I am not sure that we are talking about the same sort of patients. I don’t know which patients get referred to the NHS homeopathic hospitals, but I doubt that they are mainly those with self-limiting ailments. The patients I am thinking of are more in the area of those sometimes labelled as having “medically unexplained symptoms” they are likely to have had symptoms for months or years, and been extensively investigated. I think SkyeSteve can think of examples of who I mean, though I’m afraid, much as I agree CBT and similar therapies badly need proper provision, I don’t think that the current official approach that CBT is the answer to every difficult problem is realistic either. I can think of many patients who have had as much psychotherapy as they have had physical investigation, and more who will not or cannot countenance psychological approaches to their complaints.

@kim – thank you for your diagnosis of patronisation. Let me suggest a thought experiment for you: Put a homeopathist in the situation of a a GP, give them the same case mix and, most importantly, the same few minutes per patient with more arriving al the time, all of the data collection demanded of us, etc, and watch those approval ratings plummet. Alternatively, give medical practitioners the time to give each patient a proper hearing, and watch satisfaction with conventional medicine climb.

@elvisionary – what I was trying, badly after a heavy day, to get across is the question of what Is appropriate, and that can only be answered once you decide what your objective is. If it includes helping people to feel better, I find it very hard to say bluntly that it Is inappropriate – but that does not make me any happier about homeopathy.

jwm said,

While it is depressing to think of the use of SSRIs in most cases being placebo, policy is slowly changing, with several practices that I or colleagues have worked in only prescribing SSRIs in patients that are simultaneously being referred to tertiary care. But in a system of 60 million people and it only being 2 years since the damning meta-analyses were published it will take a while for these to slowly dissappear. Especially as it is extremely hard to deny a patient a drug which they’ve been prescribed by their doctor before ‘and works for them’.

feralboy12 said,

shockdoc said,

I am a little distressed by the discussion of SSRI medications on the comments section here, as if they were comparable to Hopey-opathy.

Biological effect versus clinical effectiveness
——————————————————-

The first idea that makes me balk is that a rational argument about drug effectiveness in real world clinical sub-populations (versus efficacy trials) is not the same as questioning whether those drugs have a biological effect. They do. These drugs have all been through years of R & D including animal studies which demonstrate biological effects. Then the scientific community takes them out and shows what other cool stuff they can do – and they do. They are associated with brain change including probably (but not definitely) neurogenesis in the hippocampus. The fact that in some mildly ill people the risk-benefit balance lies in favour of not prescribing is not really the same as the Homeopathy versus placebo argument now is it?

There are a number of logical arguments that have been stated already. There is good evidence that SSRIs do not work better than placebo in mildly depressed patients who have been enrolled in randomised-controlled trials.

However, some of the problems with (for example) the Kirsch meta-regression are:

1)The use of the words mild, moderate and severe is a by-product of the pharma companies’ classifications. All or most of these studies use the Hamilton Depression Rating Scale (Hamilton 1960). This scale has one question about mood severity and three questions about sleep. It is by definition not fit for purpose. Despite this it has become the “gold standard” for measuring pharmacological efficacy in depression trials. The pharma companies ( in an effort to make it seem like they include severely depressed people in trials ) say that anything over about 24 on the HDRS is severe depression. It is not. GPs DEFINITELY see people with depression who would score >24 on the HDRS, and by this definition definitely see people who suffer from severe depression, as measured in these trials. Take another look at the Kirsch meta regression graphs. They stop at a level of severity that reduces their clnical relevance dramatically.

2)Suicidal patients are excluded from nearly all placebo controlled trials for the obvious reason that randomising suicidal patients to placebo is considered by (most) ethics committees to be at least moderately dodgy. This excludes even moderately depressed patents with any suicidality. This in turn reduces the external validity of the trials.

3)Irving Kirsch is pretty much an expert on the placebo effect. He knows that in placebo controlled trials the effect is mediated by a)statistical regression to the mean, b) baseline inflation of scores, c)the effect of time, d)the effect of being in a trial, e)the true placebo effect. He also knows how trials run and that they have limited external validity when it comes to clinical effectiveness ( not none but limited). He knows that active comparitor studies are better for looking at effectiveness not least because they – at minimum – act as an active placebo and -at most – provide useful information about relative efficacy of the drugs. He chose to ignore all this in presenting his findings, however and sensationally presentations were taken up in the press and widely touted. I don’t think that’s very nice. In fact I think it’s a bit stinky really.

I could go on …. but I think you get my drift. Essentially, it’s just a bit more complicated than stated.

PS. Just an afterthought but… most people I see with severe depression started out without depression, then they got a little bit depressed, then they got a bit better, but then they got REALLY f**ing depressed. So SSRIs might stop people getting more depressed, mightn’t they? Not to mention the evidence supporting reduced relapse rates on SSRIs versus placebo. They don’t measure that in RCTs for the FDA though.

shockdoc said,

Also, wrt above slightly affronted GPs and patronising comments. GPs do a fabulous job of treating people. I go to mine all the time, at least 4 times a week, in fact, I think I’ve got a pain in my toe right now.

Seriously, I don’t know how you guys stick it.

GPs are treated like a filter for hospital services. Double the numbers in training say I and double the time spent with each patient and give GPs the time to do what they want to be doing, which is great medicine.

Guy said,

shockdoc, I admire your optimism!
“The fact that in some mildly ill people the risk-benefit balance lies in favour of not prescribing is not really the same as the Homeopathy versus placebo argument now is it?”
The meta-analysis didn’t look at just mildly depressed. Only those severely depressed benefited to any great degree. With NNT being about 8 for even severe depression they aint great. Remember the publication bias found out by freedom of information requests for premarketing trials. You really can’t fall back on saying they have a biological action, if that action is little better than placebo. Either they work in RCT or they don’t – end of argument. At least 90% of those treated with SSRI in primary care are outside the trial data. So it’s a placebo.

So it’s only a “bit more complicated than stated” if the answer isn’t what you want. If the RCT’s disprove homeopathy we say ban it. I was just pointing out an uncomfortable fact (for me as much as you) that SSRI’s don’t do much better than placebo either.

So nobody likes me pointing this out, but what is the place of placebo’s when used by properly qualified doctors who know they are placebos???

skyesteve said,

For those who are interested here’s the text of the Early Day Motion:-

SCIENCE AND TECHNOLOGY COMMITTEE REPORT ON HOMEOPATHY23.02.2010

Tredinnick, David (he’s a Tory in case that matters to you)
That this House expresses concern at the conclusions of the Science and Technology Committee’s Report, Evidence Check on Homeopathy; notes that the Committee took only oral evidence from a limited number of witnesses, including known critics of homeopathy Tracy Brown, the Managing Director of Sense About Science, and journalist Dr Ben Goldacre, who have no expertise in the subject; believes that evidence should have been heard from primary care trusts that commission homeopathy, doctors who use it in a primary care setting, and other relevant organisations, such as the Society of Homeopaths, to provide balance; observes that the Committee did not consider evidence from abroad from countries such as France and Germany, where provision of homeopathy is far more widespread than in the UK, or from India, where it is part of the health service; regrets that the Committee ignored the 74 randomised controlled trials comparing homeopathy with placebo, of which 63 showed homeopathic treatments were effective, and that the Committee recommends no further research; further notes that 206 hon. Members signed Early Day Motion No. 1240 in support of NHS homeopathic hospitals in Session 2006-07; and calls on the Government to maintain its policy of allowing decision-making on individual clinical interventions, including homeopathy, to remain in the hands of local NHS service providers and practitioners who are best placed to know their community’s needs.

You’ll see that Ben is specifically cited as having “no expertise” in homoeopathy but, even if that’s the case, it kind of misses the point. This report was about the lack of evidence that homoeopathy was anything more than placebo and in that respect Ben has more than enough expertise to analyse and critique the research.
Apparantly they want the NHS to determine its own local needs – well big hurrah! If only that were true and Governments kept their hands off and let them get on with it. Greater Glasgow Health Board tried to close the Glasgow Homoeopathic Hospital beds in 2004 but chickened out in the face of a determined campaign which included many politicians:-

I just feel increasingly frustrated by it all. I did sufficient homoeopathy training (3 years )that would allow me to sit the Membership of the Faculty of Homoeopathy exam. This was in the mid 1990s and I was a younger doctor trying to be open-minded. But the more I did the more I came to realise that is was nothing more that a charismatic con – pandering to the needy and offering a pill for every ill. In short – it’s crap.
Yet, despite this report, nothing will change. The homoeopaths are trotting out the same old tosh they did then – “homoeopathy doesn’t work like conventional medicine so you can’t test it like one”; “there’s no need to do RCTs because we see it working every day in our patients”;”only homoeopaths offer a true holistic approach”; blah, blah.

random592 said,

“128. The absence of a requirement to show evidence of efficacy means that the MHRA’s current arrangements would allow a person to seek, for example, a licence for a confectionary product as long as he or she persuaded a number of people that it was a homeopathic product with therapeutic effects. Such a development would, rightly, bring the licensing arrangements into disrepute.”

It’s almost as though someone cut out the “.. but of course we would never suggest anyone try doing this, oh no!”

So what! Are you suggesting it somehow validates homeopathy?
Someone fabricates results. They get found out. The system works. It doesn’t discredit all studies and all evidence for all ebm.
As regards homeopathy, all claims of “evidence” that it performs better than a placebo are false because the basic premise of homeopathy is false.

rugbycomont said,

“128. The absence of a requirement to show evidence of efficacy means that the MHRA’s current arrangements would allow a person to seek, for example, a licence for a confectionary product as long as he or she persuaded a number of people that it was a homeopathic product with therapeutic effects. Such a development would, rightly, bring the licensing arrangements into disrepute.”

You mean, like sugar pills?

Every woman I know swears chocolate is medicinal, maybe we should register that…

random592 said,

reprehensible said,

this has to be considered a victory for EBM but it’s definately a small one, i’m more worried by the review of NICE by the HSC and their response…

HSC Many PCTs struggle to afford to implement NICE technology appraisals, as well as clinical guidelines. As more interventions are evaluated it is feared that the position will become unsustainable. Funding is essentially ring-fenced for technology appraisals, leaving PCTs little room for manoeuvre in their budgets to reflect local needs and priorities. (Paragraph 241)

NICE: Our Statutory Instruments and Directions do not allow us to take budgetary impact or affordability into account when advising on cost effectiveness.

steve_s said,

JMM said,

Homeopathy industry pushes for EU-wide public healthcare support
LEIGH PHILLIPS
05.03.2010 @ 17:35 CET
EUOBSERVER / BRUSSELS – With the European Commission soon to launch a review of EU pharmaceutical laws, the homeopathy industry feels the time is ripe to launch fresh lobbying push in Brussels to have the EU force all member states to provide access to the product from public health systems and loosen up the approval process for their remedies. Representatives of the industry, practitioners and patients that use homeopathic products are to hold an EU Homeopathy Day in the European Parliament on 23 March as the kick-off for a new effort to win EU-level alternative-medicine-friendly legislation..
Industry lobbyists and their MEP allies believe that with the new European Commission expected to launch a review of EU pharmaceutical laws at some point during its four-year term, now is their chance to press their case.
“It provides an excellent opportunity for positive change,” Irish liberal euro-deputy Marian Harkin, the organiser of the event in the parliament, told EUobserver. “The aim is to integrate homeopathy into EU health policy,”
See euobserver.com/9/29620 for the full article

NOW, TIME AND RESOURCES AND EXPERTISE THAT MIGHT BE SPENT IN IMPROVING HEALTH POLICY WILL BE WASTED IN COMBATING THE NONSENSE OF HOMEOPATHY AND IN PROVING YET AGAIN THAT IT DOES NOT WORK…..
JMM

sucram said,

Most clinical research conducted on homeopathic medicines that has been published in peer-review journals have shown positive clinical results,(3, 4) especially in the treatment of respiratory allergies (5, 6), influenza, (7) fibromyalgia, (8, 9) rheumatoid arthritis, (10) childhood diarrhea, (11) post-surgical abdominal surgery recovery, (12) attention deficit disorder, (13) and reduction in the side effects of conventional cancer treatments. (14) In addition to clinical trials, several hundred basic science studies have confirmed the biological activity of homeopathic medicines. One type of basic science trials, called in vitro studies, found 67 experiments (1/3 of them replications) and nearly 3/4 of all replications were positive. (15, 16)